Upload signed Inspection Report to the Survey in DOEHRS-IH EHM per MEDCOM Policy 14-063 and then mark the Survey COMPLETED; v.Jan 2015

DOEHRS-IH EHM: RECREATIONAL WATER -- SWIMMING POOL SANITATION REPORT See TB MED 575 Page 1 of _____

1. FACILITY NAME: 2. FACILITY ADDRESS: 3. INSTALLATION: 4. START DATE: (YYYYMMDD) TIME: HH:MM

5. END DATE: (YYYYMMDD) TIME: HH:MM

6. INSPECTOR (Surveyor)

a. Name and Rank: b. Phone: c. Email: d. Unit/Organization:

7. PERSON IN CHARGE (PIC)

a. Full Name: b. Phone: c. Official Email:

8.CONTRACTOR OPERATED (select one)

Yes 9. Pool Type (select one)

Swimming Plunge/Catch Wave Other (specify):

No

10. INSPECTION TYPE: (select one)

Routine Follow-Up Complaint Pre-Opening Other (specify):

11. IS WATER HEATED?

Yes 12. DISINFECTANT TYPE: Chlorine Bromine 13. Pool Volume : gallons

No Other (specify):

Item Water Feature Information: Swimming Pool Water Feature Yes No N/A Item Water Feature Information: Swimming Pool Safety Yes No N/A

1 Pool, deck, and surrounding areas maintained and in good repair?

26 Is there adequate number of lifeguards?

2 Are spectators / tables / chairs - 10 feet from the edge of the pool?

27 Is there lifesaving equipment (e.g. shepherd’s hook, buoy ring

(U.S. Coast Guard Approved and proper length), rescue tubes, back boards)?

3 Are there adequate covered trash receptacles? 28 Is there an OSHA approved first aid kit available?

4 Are there adequate number of water closets, lavatories, urinals, showers, and drinking fountains?

29 Is an AED (Automated External Defibrillator) available and operable?

5 Is the filter / pump room clean and properly maintained? 30 Is there a working telephone with emergency numbers?

Item Water Feature Information: Swimming Pool Water Quality Yes No N/A 31 Is there a safety line (line separating the shallow and deep ends)?

6 Is a chemical test kit available? 32 Is there adequate fencing?

7 Is the total Bromine disinfectant level satisfactory? 33

Is (are) there self-closing gate(s) and are they operating correctly?

Total disinfectant level: Shallow end: ______ppm Deep end:______ ppm 34 Is the facility free of other hazards?

8 Is the free available Chlorine disinfectant level satisfactory? 35

Is it compliant with the Virginia Graeme Baker Pool and Safety Act (anti-entrapment system)?

Free available chlorine level: Shallow end: ______ppm Deep end:______ ppm 36 Are chemicals properly stored?

9 Is the pH satisfactory? pH: _____ 37 Are required Material Safety Data Sheets (MSDS) available?

10 Is the temperature satisfactory? Temperature: _____ °F 38 Are chemical warning signs properly displayed?

11 Is the visual clarity satisfactory? 39 Is Personal Protective Equipment (PPE) available?

12 Is the total alkalinity satisfactory? Total alkalinity: ______ ppm 40 If diving is prohibited, are signs properly displayed?

13 Is the calcium hardness satisfactory?

Calcium hardness: ______ ppm Item Water Feature Information: Swimming Pool Construction Yes No N/A

14 If required by regulation, has a water sample been collected for bacteriological analysis (after analysis, attach copy of results)?

41 Is the pool/spa/hot tub surface (walls and floors) easily cleaned and in good repair?

15 Is the cyanuric acid satisfactory? Cyanuric acid: _______ ppm 42 Is water on pool deck draining away from pool/spa/hot tub?

16 Is the surface water free of scum/debris? 43 Is the deck area constructed with a nonslip surface, and easy to maintain?

17 Are the bottom and sides clean; vacuumed and scrubbed daily and as needed?

44 Is water removed for treatment and recirculation through overflow gutters or skimmers / water inlets and drains?

Item Water Feature Information: Swimming Pool Operation Yes No N/A 45 Is water distribution system protected against backflow?

18 Is a copy of the rules and warnings prominently displayed? 46

Are ladders/steps with nonslip top surfaces provided at the shallow end and on each side of the deep end of the pool and in good repair?

19 Is the maximum bather load posted?

20 Are an appropriate number of qualified lifeguards/employees with documented first-aid training and CPR certifications on duty?

47 Are diving boards, slides, and other pool recreation equipment constructed of approved materials and appropriately placed to avoid injury?

21 Is an operational log properly completed? 48 Are variations in pool depth marked on the pool deck or adjacent wall/fence in sufficient increments?

22 Is a piping diagram of water and sewer lines posted near chemical equipment?

49 If a chlorine gas room is present, is it properly constructed and maintained?

23 Is a pool specification sheet available? 50 Is the filter room properly secured, ventilated, lighted, and with proper drainage?

24 Are chemical feeders operating properly? This space left Blank

25 Are hair/lint strainers operating properly?

Upload signed Inspection Report to the Survey in DOEHRS-IH EHM per MEDCOM Policy 14-063 and then mark the Survey COMPLETED; v.Jan 2015

DOEHRS -- SWIMMING POOL SANITATION REPORT See TB MED 575

Facility Date Page 2 of _____

Item Restroom/Bath-House Facilities Yes No N/A Filter Information

51 Are the walls, ceilings and floors clean? Filter Name (Brand & model):

52 Are the toilets, urinals, showers and hand basins clean? Filter Media Type:

Cartridge Diatomaceous Earth Sand

53 Is there adequate ventilation and lighting? Influent pressure gauge

PSI Effluent pressure gauge

PSI

54 Are clothing, swimsuits and towels properly handled? Filter operating properly? Yes No

55 Is the baby changing station clean? Filter backwashed as need? Yes No

56 Are soap, toilet paper, paper towels, and trash receptacles available?

Filter Comments:

Pump Information

Pump Name (Brand & model):

Rate of flow (Comment required if value is zero): gal/min

Pump operating properly? Yes No Pump Comments:

Turnover Rate*: Times/24-hours This space left Blank

*Note: Turnover Rate is the number of turnovers that occur in a 24-hour period. A Turnover is the length of time needed for the pool to circulate its entire volume one time. TB MED 575 specifies the maximum Turnover Time allowed for each aquatic venue.

Turnover Time = 24 hours ÷ Turnover Rate

Turnover Rate = 24 hours ÷ Turnover Time

14. OVERALL REMARKS (describe individual Item deficiencies here)

**Water samples taken during this inspection:

Yes Sample Type:

HPC **Note: Attach a copy of the sample results to this inspection document and upload the results to the inspection report in DOEHRS. No Coliform (Total or E.coli)

15. INSPECTION RATING:

Satisfactory Unsatisfactory

16. FOLLOW-UP

REQUIRED:

Yes No

17. FOLLOW UP DATE NLT: (YYYYMMDD)

18. SIGNATURE: Signature on this form represents acknowledgment that the person in charge has been briefed on the deficiencies noted, corrective actions and timeframe to complete, the final inspection rating, and the date scheduled for follow-up inspection (unsatisfactory inspections only).

a. Inspector Signature b. DATE (YYYYMMDD):

c. Person in Charge Signature

d. DATE (YYYYMMDD):